HANCOCK COMMUNITY HEALTH PLAN

4500

$4,500 Deductible Plan: Cost-Effective Coverage for Health-Conscious Employees Ideal for Employers with a workforce that prefers lower premiums and is comfortable with higher deductibles.

Features:

$4,500 Individual / $9,000 Family Deductible: Higher deductible leading to lower premiums.
$0 Cost Services: Access to key services at no cost, promoting preventive care.
Tier 1 Care Coordination: Assistance in finding cost-effective care options within the Hancock Health system.

Benefits:

Reduced premium costs for employers.
Employees have the opportunity to save on premiums while still accessing essential services at no cost.
Supports local healthcare providers, strengthening community health initiatives.

PLAN DETAILS

SERVICE	TIER 1 Hancock Health and Preferred Network	TIER 2 PHCS for VDHP or Participating Providers	TIER 3 Non-Participating Providers	LIMITS / INFO
Deductible (Individual / Family)	$0 /$0	$4,500 / $9,000	$4,500 / $9,000	N/A
Out of Pocket Max (Individual / Family)	$8,700 / $17,400	$8,700 / $17,400	$17,400 / $34,800	N/A

PHYSICIAN SERVICES

SERVICE	TIER 1 Hancock Health and Preferred Network	TIER 2 PHCS for VDHP or Participating Providers	TIER 3 Non-Participating Providers	LIMITS / INFO
Preventative Care*	N/A	$0	$0	As Outlined by the Affordable Care Act
Primary Care Visit	N/A	$40 Copay	$40 Copay	N/A
Specialist Care Visit	N/A	$60 Copay (Office) 20% Coinsurance (Outpatient Hospital)	$60 Copay (Office) N/A (Outpatient Hospital)	N/A
Chiropractic Services	N/A	$60 Copay	50% Coinsurance	Limited to 12 Visits Per Plan Year
Physical Rehabilitation	$0	$60 Copay	50% Coinsurance	Penalty for Failure to Obtain Prior Authorization Limited to 30 Visits Per Year
Mental Health Outpatient	$0	$60 Copay (Office) 30% Coinsurance (Outpatient Hospital)	50% Coinsurance (Office) N/A (Outpatient Hospital)	N/A
Mental Health Inpatient	$0	20% Coinsurance	20% Coinsurance	Penalty for Failure to Obtain Prior Authorization
Urgent Care	N/A	$70 Copay (Office) 20% Coinsurance (Outpatient Hospital)	50% Coinsurance (Office) N/A (Outpatient Hospital)	N/A

*Routine Adult & Child Care | Immunizations | Cancer Screenings | Mammograms | OB/GYN Visits

HOSPITAL SERVICES

SERVICE	TIER 1 Hancock Health and Preferred Network	TIER 2 PHCS for VDHP or Participating Providers	TIER 3 Non-Participating Providers	LIMITS / INFO
Diagnostic Test (X-Ray / Blood Work)	N/A (Bloodwork) $0 (X-Ray)	$50 Copay (Individual Lab) 30% Coinsurance (Outpatient Hospital)	50% Coinsurance (Individual Lab) N/A (Outpatient Hospital)	N/A
Advanced Imaging (CT / MRI / PET)	$0	30% Coinsurance	50% Coinsurance	Penalty for Failure to Obtain Prior Authorization
Emergency Room	N/A	30% Coinsurance	30% Coinsurance	N/A
Ambulance	N/A	30% Coinsurance	30% Coinsurance	N/A
Hospital Stay And Outpatient Procedures	$0	30% Coinsurance	30% Coinsurance	Penalty for Failure to Obtain Prior Authorization
Childbirth / Delivery Services	$0	30% Coinsurance	30% Coinsurance	Penalty for Failure to Obtain Prior Authorization

PRESCRIPTIONS

30/90 Day

Generics: $0 / $0 Copay

Formulary Brand: $45 / $90 Copay

Non-Formulary Brand: $90 / $180 Copay

Specialty: Contact Care Coordination

Rx Deductible (Individual / Family): $250 / $500

Rx 30-Day Supply is Retail Only, 90-Day Supply is Retail or Mail Order. Please See the Plan Documents for Complete Coverage Details, Limits, and Exclusions.

HANCOCK COMMUNITY HEALTH PLAN